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Virtual Reality as Therapy
Credit: Anna Stills
A child once described their complex regional pain syndrome (CRPS) to Stanford University professor of anesthesiology Brenda Golianu as feeling like "an orchestra of pain." Typically the condition requires treatment with multiple therapies, including nerve blocks, ketamine infusions, medications, intensive physical therapy, and psychology. Golianu recalls one example of a 12-year-old girl suffering from CRPS of the lower-right leg; she walked only with a crutch. She had been given all the treatments described here, but Golianu and her colleagues added an additional element based around a virtual reality (VR) game.
The researchers were testing VR as a way to incentivize children to move and work through difficult but beneficial physical therapy exercises and drive significant rehabilitative progress. They designed a game, Fruity-Feet, specifically for pediatric rehabilitation. FruityFeet situates the player in a virtual farm and instructs them to smash digital fruits and vegetables as a timer runs down.
When this particular girl took part, she entered the treatment room relying on her crutch. She then donned an immersive VR headset from the company Vive, set her walking aide aside, and proceeded to play. Sensors tracked the girl's movements, and she would receive more points if she lifted her leg higher. She was more active and likely to engage in difficult movements—a trend that emerged throughout the larger study.
"We have videos of kids coming in on crutches, stomping their feet during gameplay, then taking off the headset and using crutches again," explains Golianu. "The gains don't transfer automatically to the reality we live in, but often the kids are able to do more in virtual reality than they do in physical therapy."
This use of VR is just one example of how scientists and medical professionals are turning precisely designed alternate realities into therapeutic tools. Today, VR is helping patients overcome phobias, post-traumatic stress disorder (PTSD), a variety of musculoskeletal injuries and ailments, and more.
Until recently, headsets were too expensive, too heavy, and required cables and other hardware, according to Matthew Stoudt, CEO of AppliedVR, which has an FDA-authorized product for lower back pain called RelieVRx.
Now that is changing. The metaverse might not have arrived on schedule, but the technology improvements it generated, combined with ingenious research, have opened up incredible potential for novel treatments. "The latest headsets are marvels of display technology compared to what we had available just a couple of years ago," says psychologist Albert "Skip" Rizzo, director of Medical Virtual Reality at the University of Southern California's Institute for Creative Technologies. "They have gotten so good that we can do really valuable work in therapy. The technology has finally caught up to the original vision."
A New Treatment Option
That original vision traces back to the 1990s. Emory University psychologist Barbara Rothbaum published the first paper looking at the potential use of VR as a treatment for psychiatric disorders in 1995. Rothbaum effectively helps patients confront their fears and learn to manage them through what is known as exposure therapy. If someone has a fear of flying, for example, Rothbaum might arrange to fly with the patient to help them manage and work through their fears in real time. This technique is effective, but it is also expensive and not particularly scalable—a therapist could only do this work with so many patients, given the time commitment.
With VR, a patient who has an acute fear of flying can don an immersive headset and embark on a simulated flight. Rothbaum and her team can control the conditions precisely, too. "If my patient's not ready for turbulence, I can guarantee there won't be turbulence," she says. "We can take off and land as many times as we need, all within a five-minute therapy session right in my office."
One of her studies showed that 90% of such patients who had successful VR exposures flew on actual airplanes within a year of the treatment. These were individuals whose fear was so acute that they would drive from Atlanta to Los Angeles rather than fly, or travel by boat to Europe. "It doesn't matter if someone can get on a virtual airplane if they can't get on a real airplane, but it really does seem to translate."
Rothbaum and her team have also done pioneering work in using VR for PTSD in collaboration with Rizzo. He notes there are now thousands of research studies documenting the value of applying these technologies to different areas of mental health and physical rehabilitation. In some cases, the effectiveness of VR is not necessarily better than traditional approaches, but the technology has the potential to draw in and reach more people.
Other examples reveal unique advantages. A study from Rothbaum, Rizzo, Cornell University psychologist JoAnn Difede, and others showed that VR exposure therapy is particularly beneficial for patients with comorbid depression and PTSD. "We could emotionally activate their trauma memories in a way that was more powerful and achieve better clinical outcomes using VR," says Rizzo.
Gamification
The use of VR for therapy is not confined to trauma and phobias. There are a number of applications similar in spirit to the FruityFeet game, as one of the core advantages of the medium is its ability to engage the user through play. At the Motor Control Lab at Virginia Commonwealth University, director James Thomas has been rigorously studying the use of VR for physical therapy, and for chronic back pain in particular. People who suffer back injuries sometimes develop a fear of moving; they worry that if they move the wrong way, they will aggravate their injury. However, Thomas explains that a lack of movement can lead to harmful changes in the muscles, ligaments, tendons, and tissues that support the spine. That is why Thomas and his team started looking at the role fear played in motivating people to avoid certain movements, and eventually reasoned that a VR game might be a good way around the problem.
Today, Thomas and his lab are refining a suite of games geared toward physical rehabilitation. One is set on a dock jutting out into a virtual lake; players need to reach forward and catch fish with a digital net as they leap out of the water—how far and how quickly they have to reach is precisely tuned to their needs. The most physically demanding game is a virtual version of dodgeball specifically designed to encourage particular movements. A player dons the headset and enters a fully immersive competition, complete with cheering and booing fans. The avatar is scaled to match the user's body, from hip height to arm length, so movements are accurately matched. Players have to dodge virtual balls thrown their way, and the game can be adjusted to make the balls travel faster or slower, depending on where the patient is in his or her therapy.
Today, VR is helping patients overcome phobias, post-traumatic stress disorder, a variety of musculoskeletal injuries and ailments, and more.
The goal, Thomas explains, is to induce specific movements the patient has been otherwise avoiding. "It turns out that when you draw people into an environment where they are not thinking about moving, and there's clapping and booing, their natural competitive instincts emerge and they move," Thomas says. "If I launch a virtual ball into a particular part of space, I know that I can get you to move your spine a certain way, and then I can manipulate the game's controls to get you to move more or less, depending on your needs."
A recent study of 175 patients who took part in 3,500 individual testing sessions yielded encouraging results, with significant reduction in pain and fear of movement.
Technology and Outlook
In general, while they applaud the development efforts of Meta, Apple, Vive, and other large companies and manufacturers, the experts are not beholden to any particular VR headset. Rizzo would like to see the headsets become less expensive and easier for both physicians and patients to use.
AppliedVR's Stoudt echoes this point, noting that ease of use is essential for his company, given that their vision calls for patients using these headsets on themselves at home.
Display resolution is not a primary concern. Rothbaum's research has shown that even cartoonish renderings can have a huge effect. "If you have someone who is scared of snakes, if they even see a picture of a snake, they're going to feel fear," she says. "People get scared in virtual reality, and if you stay in it long enough, that fear decreases."
Currently, AppliedVR is deploying its treatments through headsets manufactured by VR leader PICO. Stoudt says PICO gave his team access to its hardware and operating system so they could optimize the design and better prepare for FDA authorization. AppliedVR also created a solution to capture breath, and measuring biodata may become increasingly popular. Generally, Stoudt believes there will be significant technological development in the years ahead.
"The next stage of the headsets is that you're going to see them become true computing platforms," Stoudt says. "It took the field a long time to get here, but now we're going to see rapid acceleration."
Further Reading
Bordeleau, M. et al.
The use of virtual reality in back pain rehabilitation: A systematic review and meta-analysis. The J. of Pain 23 (2022), 175–195.
Difede, J. et al.
Enhancing exposure therapy for posttraumatic stress disorder: virtual reality and imaginal exposure with a cognitive enhancer: a randomized clinical trial. Translational Psychiatry 12, 1 (2022), 1–9.
Griffin, A. et al.
Virtual reality in pain rehabilitation for youth with chronic pain: Pilot feasibility study. JMIR Rehabilitation and Assistive Technologies 7, 2 (2020), e22620.
Rizzo, A.A. and Koenig, S.
Is clinical virtual reality ready for primetime? Neuropsychology 31, 8 (2017), 877–899.
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